Agency Nursing Staff FALL PREVENTION TUTORIAL

Staff Printed Name: ___________________________ Staff Position: ________________________________

Fall Prevention SOP’s 1. Nursing Rounds Requirement 2. Bed Exit Alarm System Morse Scale/Scoring 1. Preventive Strategies 2. Protective Strategies Fall Risk Assessment 1. Documentation of fall risk within 24 hours of admission 2. Document plan of care with Morse Score of 45 or > in Admission Assessment template versus Nursing Progress Note template Fall Risk Reassessment 1. Assess for fall risk upon hand off, change in condition and post fall Fall Coordinator Consult via CPRS

Staff Initials

Agency Staff Signature: _________________________________ Agency Staff Printed Name: _____________________________ Name/Position of Instructor: ____________________________ Agency Coordinator Signature: ___________________________

Date: __________________________ Agency: ________________________

Agency Initials

Comments

Date: ____________________ Date: ____________________

Fall Prevention Guidelines - RN’s Only Patient must have documented plan of care with interventions for Morse Score of 45 or > Is the patient a new admit?

Reassessment patients for fall risk at hand-off, change in condition and post fall

No

Yes Use Admission Assessment to document fall risk w/in 24 hrs of admit

Is the patient admitted with a fall history with a Morse Score of 60 or >?

If the patient has a inpatient fall , refer to Fall Coordinator.

Yes

Implement protective measures, i.e., chair/bed alarm, low bed, floor mats, hipsters

No Implement preventive measures, i.e., nursing rounds – potty, pain, positioning, personal items

Yes

Implement standard fall precautions and place Fall Coordinator Consult

Consider companionship as last resort

MORSE FALL SCALE/SCORING FALL INTERVENTION STRATEGIES BY MORSE SCALE ITEM Morse Fall Scale Item 1. History of Falling

Assessment Goal To Prevent Recurrence of Falling

2. Secondary Diagnosis

To determine the interactions from poly-pharmacy

3. Gait

To assess impairment of gait & balance

Preventive Strategy Expect a 2nd fall; develop a strategy to prevent recurrence-at the same time with the patient doing the same activity. Develop a patient specific fall intervention plan Consult with physician and pharmacy. Adjust medications accordingly. Refer to PT for exercise program. Provide low bed, safe route to bathroom-handholds? Rails? Inform family about limitations and plan for fall prevention

4. Ambulatory Aide

To assess appropriate walking aids

5. IV

To maximize safe ambulation; reduce urinary urgency

6. Mental Status

Improve orientation and acceptance of changed abilities

Avoid “rushing to BR; check bladder and bowel function. Needs a walking aid? Provide appropriate aids (this will reduce the fall risk score. Aids used correctly? Within reach? Educate. Assess for fluid balance, hypotension. If using pole as walking aid, provide walker. If urinary urgency, wake at 2 am for toileting Frequent observation, place bed in room by nursing station. Hourly comfort rounds.

Protective Strategy Alert staff regarding the circumstances of the 1st fall (communicate fall risk). Perform hourly rounds Consider Vitamin D replacement therapy Weak Gait: Remind to use call light for assistance when getting out of bed; use handrail; plan route Impaired Gait: Gait belt when walking. Provide assistance. Top side up to assist with mobility. If non-compliant – use bed/chair alarm If wheelchair user, observe transferring technique

Remind about physical limitations

Frequent reorientation and reminders Bed/chair alarms

MORSE FALL SCALE/SCORING FALL INTERVENTION STRATEGIES BY MORSE SCALE ITEM Implement bowel/bladder program Involve family for observations, planning care

Do not leave unattended in diagnostic areas or BR > 15 minutes If gait impaired, use bed alarm, chair alarm and low bed Consider use of companion Indicate fall risk via “Prevent a Fall” magnet

Standard Operating Procedure for Patient Rounding Purpose: To decrease the incidence of falls and promote patient safety on the inpatient units 5 North, 5 South, and 4 South at ECHCS by ensuring nursing staff consistently round every two hours or hourly for those patients identified as high fall risk per Morse score 45 or > to assess pain, offer assistance with toileting and repositioning and assess the environment for fall hazards.

Definitions: Nursing Staff- Registered Nurses and Nursing Assistants Rounding – A systematic monitoring of all patients present on the unit by visualization and/or interaction. Morse Scale- The Morse Fall Scale is a rapid and simple method of assessing a patient's likelihood of falling. The Morse score is obtained by using variables and numeric values, the sum of the scores is the Morse Fall Scale Score. Rounding Tool- The rounding tool is an optional checklist to guide new staff and agency staff on the rounding practice.

Responsibilities: Associate Chief Nursing Service, ACNS /Inpatient Care Oversight of the program to ensure compliance within Patient Care Services. Nurse Manager/Nursing Supervisor To oversee, monitor, and supervise all nursing staff on the 5 North, 5 South and 4 South units to ensure all are following standard operating procedure (SOP). Charge Nurse To maintain knowledge of the expectation for every one to two hour rounding and SOP and ensure compliance among staff.

2/11/2011 JP/JG/LD/DM

Staff Registered Nurse To maintain knowledge of the expectation for every one to two hour rounding and SOP and ensure compliance on his/her assigned patients. Ensure compliance through delegation and collaboration.

Nursing Assistant To maintain knowledge of the expectation for every one to two hour rounding and SOP and ensure compliance on his/her assigned patients. Ensure compliance through collaboration.

Procedure: Registered Nurse or Nursing Assistant will provide systematic monitoring of all patients present on the unit by visualization and/or interaction every two hours and every one hour for patients identified as a high fall risk. Registered Nurses will use the optional tool when needed to assist in delegation to ensure compliance. Nursing Assistants will use the optional tool when needed to ensure compliance.

2/11/2011 JP/JG/LD/DM

Standard Operating Procedure for Patient Rounding

I have been given the opportunity to read and ask questions related to the Standard Operating Procedure for Patient Rounding. I have received a copy of the Standard Operating Procedure for Patient Rounding. I have received a copy of the optional rounding tool. I understand the information that has been presented to me. I will comply with the expectations set forth in the Standard Operating Procedure for Patient Rounding.

___________________________ Printed Name

___________________________ Signed Name

2/11/2011 JP/JG/LD/DM

________________ Date

2/11/2011 JP/JG/LD/DM

High Fall Risk Hourly Rounding Check List Perform each task & initial each column at least every 2 hours daily Rounds are performed every two hours between 10pm – 6am Day Staff Signature/Title______________________ Evening Staff Signature/Title__________________________ Night Staff Signature/Title____________________________

Patient Name:________________ 8:00 Offer toileting, check bed for soiling Reposition/turn patient q 2 hours if awake; side rails x2 prn Assess pain (if staff is not RN, report patient pain to RN immediately) Bed in low position q day; bedside rails x2 as needed Side table decluttered & cleaned; Kleenex at bedside Side table, telephone, overhead light switch, call light & urinal within reach Water offered/water pitcher filled Room de-cluttered, i.e., clean & store unused equipment Floor de-cluttered., i.e., detangle and secure lines, tubing, and cords Reinforce nurse call assistance Ask, “is there anything else I can do for you while I’m in the room?”

9:00

10:00

11:00

noon

1:00

2:00

3:00

4:00

Patient Room #:________________ 5:00

6:00

7:00

8:00

9:00

10:00

MidNight

2:00

4:00

6:00

7:00

High Fall Risk Hourly Rounding Check List Perform each task & initial each column at least every 2 hours daily Rounds are performed every two hours between 10pm – 6am Day Staff Signature/Title______________________ Evening Staff Signature/Title________________________ Night Staff Signature/Title____________________________

Patient Name:________________ Monday Offer toileting, check bed for soiling Reposition/turn patient if awake; side rails x2 prn Assess pain (if staff is not RN, report patient pain to RN immediately) Bed in low position q shift Side table decluttered & cleaned; Kleenex at bedside Side table, telephone, call light & urinal within reach Water offered/water pitcher filled Room de-cluttered, i.e., clean & store unused equipment Floor de-cluttered., i.e., detangle and secure lines, tubing, and cords Reinforce nurse call assistance Ask, “is there anything else I can do for you while I’m in the room?”

Community Living Center

Tuesday

Wednesday

Thursday

Friday

Patient Room #:________________ Saturday

Sunday

Comments

High Fall Risk Hourly Rounding Check List Perform each task & initial each column at least every 2 hours daily Rounds are performed every two hours between 10pm – 6am

Department of Veteran Affairs Eastern Colorado Health Care System Patient Care Services April 13, 2012

OG 118-

Standard Operating Procedure (SOP) Title: Bed/Chair Alarm Usage Purpose: In an effort to control inpatient fall events, use of bed and chair alarms is an important element of the VA ECHCS fall prevention program. In addition to portable Bed Check chair and bed alarms, the Stryker Secure II beds are equipped with “zoned” bed exit alarms to alert staff to a potential patient fall. Bed Check chair and bed alarms are detachable devices that use a sensor (strip) to monitor a patient’s movement either in a bed or chair. Should the patient attempt to rise, an alarm sounds to alert the staff of a potential fall. The Stryker Secure II bed exit alarm system is armed by following three simple steps:

OG 118-

April 13, 2012

The Stryker Secure II is divided into three separate zones and allows the caregiver to select system sensitivity based on the patient fall risk. Bed and chair alarms are beyond standard fall precautions and are considered extra ordinary measures to fall prevention. Finally, bed & chair alarms are not “sound proof.” The current layout of patient care units with a centralized nursing station does not allow for good visual or auditory patient observation. Therefore, it is necessary to use extraordinary measures to protect patients from harm due to falls. Definitions: Nursing Staff - Registered Nurses, Licensed Practical Nurse and Nursing Assistants. Bed Check Bed/Chair Alarms – A detachable alarm device for bed or chair with sensor to alert staff to a potential patient fall event. Stryker Secure II Bed Exit Alarms – Zone controlled bed exit alarm system allows staff to assess the patient fall risk based on their center of gravity in relation to a chosen zone. Responsibilities: Associate Chief Nursing Service, ACNS Inpatient Care: a. Support funding for nursing/patient safety. Nurse Managers: a. Endorse daily communication of high fall risk patients among staff. b. Support hourly rounding initiative. c. Ensure equipment failures (non-working bed alarm system) are reported to FMS within 24 hours for repair. Registered Nurse: a. Communicate patient fall risk at hand-off. b. Communicate high fall risk patients to LPN, CNA staff. c. Assure CNA staff perform hourly rounds on high fall risk patients. d. Do quick visual scan of the patient environment and correct fall hazards. e. Obtain bed/chair alarm & sensor strip from TSS. f. Activate bed/chair alarm by inserting sensor into alarm & placing the sensor underneath the patient mattress or seat. g. Or, activate bed exit alarm in appropriate zone (dependent upon patient risk). 2

OG 118-

April 13, 2012

h. i. j. k. l.

Educate patients on the use of bed and chair alarms when in use. Assure bed alarm operable when changing linen. Perform hourly rounds on high fall risk patients. Ask the patient, “is there anything else I can do for you?” before leaving the room. Stay within close proximity while high fall risk patients toileting; do not leave alone > 10 minutes. m. Stay within close proximity while high fall risk patients showering; do not leave alone > 20 minutes. n. Remind patients to use pull cord when finished. Licensed Practical Nurse: a. Activate bed/chair alarm by inserting sensor into alarm & placing the sensor underneath the patient mattress or seat. b. Or, activate bed exit alarm in appropriate zone (dependent upon patient risk). c. Assure bed alarm operable when changing linen. d. Perform hourly rounds on high fall risk patients. e. Ask the patient, “is there anything else I can do for you?” before leaving the room. f. Do quick visual scan of the patient environment and correct fall hazards including unused linen. g. Stay within close proximity while high fall risk patients toileting; do not leave alone > 10 minutes. h. Stay within close proximity while high fall risk patients showering; do not leave alone > 20 minutes. i. Remind patients to use pull cord when finished. Certified Nurse Assistant: a. Activate bed/chair alarm by inserting sensor into alarm & placing the sensor underneath the patient mattress or seat. b. Or, activate bed exit alarm in appropriate zone (dependent upon patient risk). c. Assure bed alarm operable when changing linen. d. Perform hourly rounds on high fall risk patients. e. Ask the patient, “is there anything else I can do for you?” before leaving the room. f. Do quick visual scan of the patient environment and correct fall hazards including unused linen. g. Stay within close proximity while high fall risk patients toileting; do not leave alone > 10 minutes. h. Stay within close proximity while high fall risk patients showering; do not leave alone > 20 minutes. i. Remind patients to use pull cord when finished.

3

OG 118-

April 13, 2012

Patient Safety Coordinator: a. Manage program effectiveness in coordination with nursing staff. b. Educate staff on fall prevention initiatives. c. Collaborate with unit specific fall champions. d. Provide quarterly unit specific data. e. Support fall prevention initiatives, i.e., nursing rounds. f. Perform nursing rounds. I have been given the opportunity to read and ask questions related to the Standard Operating Procedure for Bed, Chair and Alarm Usage. Approve / Disapprove

_______________________________ Judith Burke, MS, RN, NEA-BC Associate Director for Patient Care Services

__________________________ Date

I have received a copy of the Standard Operating Procedure for Bed, Chair and Alarm Usage. I understand the information that has been presented to me.

_________________________________ Employee Printed Name

_________________________________ Signature

_____________________________ Date

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